Principles of radiology report.

1. Presented By.
Dr. Mahmoud Tawfik (MSc).

2. How to Read Your Radiology Report
Imaging studies such as magnetic resonance imaging (MRI), computed tomography (CT),
ultrasound, nuclear medicine or X-ray exams play an increasingly important role in the
diagnosis and treatment of disease. After completing an imaging study, the radiologist will
analyze the images and prepare a report summarizing the findings and impressions.
Electronic Health Records
Many patients today can access their health records — including radiology reports —
electronically online. Electronic access to health records allows patients to make more
informed healthcare decisions in partnership with their physicians. Furthermore, patients
are empowered to electronically share radiology reports with other medical providers. Such
access potentially increases the safety, quality and efficiency of patient care.
The radiology report is primarily a written communication between the radiologist
interpreting the imaging study and the physician who requested the examination. Typically,
this radiology report is sent to the physician who originally requested the imaging study
and who then conveys the results to the patient. Many patients can also directly access their
radiology reports and, in some cases, their medical images using online patient portals and
electronic health records.

3. These records and reports often contain complex anatomical and medical terms. Examples
and descriptions of the sections within a radiology report may be found below, including:
 type of exam
 clinical history
 comparison
 technique
 findings
 impression
The intent of this article is to provide a basic orientation to the structure and content of a
radiology report. Because radiology reports may contain complex technical and medical
information, a comprehensive explanation of the contents of the report are beyond the
scope of this article. Talk to your physician about any questions you may have about your
radiology report

4. Sections of the Radiology Report
Type of exam
The type of exam section indicates the date, time and type of imaging study that was
performed.
Example:
 Computed tomography (CT) of the abdomen and pelvis with intravenous and oral
contrast performed January 10th, 2014.
Clinical history
The clinical history section lists patient information such as age, gender and relevant
clinical information, including any existing disease and symptoms. If a diagnosis is known
or suspected, it will be listed here, along with the indication or reason for the imaging study
or the clinical question being asked. The availability of this information enhances the
radiologist’s ability to focus the report on each patient’s unique condition.
Example:
 64 year-old female with history of breast cancer and new onset abdominal pain.

5. Comparison
If the radiologist compared the imaging study with any of the patient’s previous imaging
studies, it will list them in the comparison section. Comparisons are most commonly made
to exams of the same body region and study type.
Example:
 Comparison is made to an ultrasound of the abdomen performed August 24, 2013.
Technique
The technique section describes how the imaging study was performed, including whether
or not a contrast material was used. Because it is used for documentation purposes, this
section is not typically useful for the patient or the referring physician. It can be very
helpful to a radiologist to direct the performance of a future exam.
Example:
 5 mm axial images from the lung bases through the pubic symphysis were acquired
following the administration of intravenous and oral contrast. Coronal and Sagittal
reformatted images were constructed from the source data.

6. Findings
The findings section lists the radiologist’s observations and findings regarding each area of
the body examined in the imaging study. The radiologist indicates whether each area was
found to be normal, abnormal or potentially abnormal. Sometimes an area of the body is
included and can be evaluated using the images, but is not discussed. This situation
typically means that the radiologist did not find the area noteworthy for comment.
Example:
 Lung bases: No pulmonary nodules or evidence of pneumonia.
 Cardiac: Base of heart is within normal limits. No pericardial effusion.
 Liver: Normal size and contour. There is a new 2 cm hypoattenuating focus in
segment 8. Gallbadder is surgically absent.
 Biliary: No intra or extrahepatic biliary dilation.
 Spleen: No splenomegaly.
 Pancreas: No mass or ductal dilation.
 Kidneys and Adrenals: No masses, stones or hydronephrosis. No adrenal nodules.
 Lymph nodes: No lymphadenopathy.
 Bowel: No dilation or wall thickening.
 Bladder: Within normal limits.
 Uterus and Adnexa: The uterus and bilateral ovaries are within normal limits for
age.
 Bones: No aggressive osseous lesions. Degenerative changes are present in the
spine.
 Soft Tissues: Bilateral fat and bowel containing inguinal hernias are again noted.
 Other: No free fluid within the pelvis.

7. Impression
In the impression section, the radiologist combines the findings, patient clinical history and
indication for the imaging study and provides a diagnosis. Because this section offers
critical information for decision-making, it is considered to be the most important part of
the radiology report.
For an abnormal finding, the radiologist may recommend:
 additional imaging
 biopsy
 correlating the finding with clinical symptoms or laboratory test results
 comparing the finding with prior imaging studies, if available.
For a potentially abnormal finding, the radiologist may make any of the above
recommendations in addition to recommending follow-up imaging to assess whether the
area remains the same or changes.
If a precise clinical diagnosis is not possible, the radiologist may offer a differential
diagnosis, which is a list of possible diagnoses based on the imaging findings and the
patient’s clinical history.
If the report does not answer the clinical question, additional or follow-up imaging studies
may be indicated. Additional studies may also be recommended to follow-up on a
suspicious or questionable finding.
Example:
1. No findings on the current CT to account for the patient’s clinical complaint of
abdominal pain.
2. There is a new 2 cm lesion in the liver which is indeterminate (cannot be definitively
diagnosed by the study).
3. RECOMMENDATION: Given the patient’s personal history of breast cancer, an
MRI of the liver is recommended to better characterize the indeterminate liver
lesion to exclude the possibility of metastases (or cancer spread).

8. AdditionalInformation
Oncetheradiologyreportiscompletedandsigned,itissenttothereferringphysicianwho
canthendiscusstheresultswiththepatient.Thereportmayalsobeuploadedtoanonline
electronichealthrecordwherethepatientmayaccessit.
Ifyouhavequestionsaboutyourradiologyreportthatyourreferringphysiciancannot
answer,talktoyourimagingfacilitystaff.Manyradiologistswillmakethemselves
availabletopatientstoansweranyquestionstheirreferringphysiciancannotanswer.

9. Thank
you